Pediatric Vomiting

Vomiting, or emesis, is the forceful oral expulsion of gastric contents. Vomiting is a common presenting symptom in pediatrics. The frequency and characteristics of vomiting may point toward a specific pathology, just as its presence can be another symptom of a greater clinical situation. The majority of vomiting symptoms are benign and self-limited. A good history and physical examination can bring into focus the underlying cause and workup. Management is with antiemetics and treating the underlying cause, if needed. The most common complications are dehydration and malnutrition.

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Definition and Etiology

Definition

Vomiting (emesis) refers to the forceful oral expulsion of gastric contents.

Etiology

  • Newborns:
    • Esophageal atresia
    • Vascular rings
    • CNS lesions
  • Infants:
    • Gastroenteritis
    • Pyloric stenosis
    • GERD
    • Food allergies
    • Milk-protein intolerance
    • Overfeeding
    • Inborn errors of metabolism
    • Vascular rings
  • Children and adolescents:
    • Gastroenteritis
    • Pyelonephritis
    • Systemic infection
    • Toxic ingestions
    • Appendicitis
    • Ulcers
    • Pancreatitis
    • Pregnancy

Clinical Presentation

History

A complete history should be elicited to narrow the differential diagnosis of vomiting in a child.

  • Demographics:
    • Age
    • Sex
    • Place of residence (important in cases of epidemics and food poisoning)
  • Onset/duration/progress of symptoms
  • Association of food intake
  • Fluid balance:
    • Number of wet diapers/urinations per day
    • Increase in drinking or asking for water
  • Associated symptoms:
    • Fever
    • Earache
    • Headache
    • Abdominal pain
    • Dysphagia
    • Chest pain (referred heartburn in esophagitis)
  • Nature of the vomitus:
    • Projectile/nonprojectile
    • Color
    • Contents
    • Painful/painless
    • Hematemesis can occur in:
      • Mallory–Weiss syndrome (indicating forceful vomiting)
      • Coagulopathies
    • Severe, persistent vomiting in cases of:
      • CNS compromise (meningitis in children, hydrocephalus)
      • Metabolic derangement
      • Chemotherapy-induced
    • Sexual activity in adolescent girls (for potential pregnancy-induced vomiting)

Physical examination

  • Fever in GI and CNS infections
  • Bulging or sunken fontanelle:
    • Bulging (↑ intracranial pressure)
    • Sunken (dehydration)
  • Poor feeding
  • Signs of dehydration or shock (fluid replacement therapy in children)
  • Low height and weight for age in cases of anorexia due to loss of calories and nutrients:
    • Failure to thrive
    • Malnutrition
  • Nystagmus in vestibular disorders (vertigo)
  • Marked abdominal distention and tenderness in appendicitis or acute abdomen
  • Presumptive signs of pregnancy
Table: Degree of dehydration in children
MildModerateSevere
Weight loss
  • < 5% in infants
  • < 3% in older children
  • 5%–10% in infants
  • 3%–9% in older children
  • > 10% in infants
  • > 9% in older children
Dry mucosa (first sign)+/– (looks dry)+ (looks parched)
Skin turgor (last sign)++/–– (tenting)
Anterior fontanelle depression++/++
Mental statusNormalFatigued/irritableApathy/lethargy
Enophthalmos++
BreathingNormalDeep, maybe tachypneicDeep and tachypneic
Heart rateNormalIncreasedVery high
Hypotension++
Distal perfusionNormal
  • Feels cold
  • 3–4 sec
  • Acrocyanotic
  • > 4 sec
Urinary outputDecreasedOliguriaOliguria/anuria
Table: Characteristics of vomitus according to level of obstruction
Nature of vomitusApproximate level of obstruction
Nonbilious acidic vomitusDistal to stomach, proximal to duodenum
Bilious vomitingDistal to 2nd part of duodenum
Feculent vomitusObstruction in the large bowel
Nondigested food contentProximal obstruction

Diagnosis and Management

Laboratory testing

  • Basic metabolic panel: 
    • In cases of severe dehydration can show: 
      • ↓ Glucose
      • ↑ BUN
      • ↑ Sodium and chloride
      • ↓ Bicarbonate
      • ↑ Creatinine
  • CK: 
    • When concerned about rhabdomyolysis
    • Elevated in severe dehydration

Pharmacologic therapy

  • IV hydration for:
    •  Hypovolemic shock
    • Severe dehydration
    • Intractable vomiting
  • Antiemetics:
    • Ondansetron IV or oral (first line)
    • Metoclopramide oral or IV
    • Dimenhydrinate orally (in motion sickness for ages 12 and up)

Nonpharmacologic therapy

  • Oral rehydration (preferred and is first line in mild or moderate dehydration)
  • Surgical intervention for intestinal obstructions (i.e., pyloric stenosis)
  • Proton pump inhibitors (PPI) in peptic disease (i.e., gastroesophageal reflux disease)

Mild to moderate dehydration

  • Oral rehydration therapy (ORT) is first-line treatment in mild or moderate dehydration.
  • Oral rehydration solutions with electrolyte contents similar to those of fluid lost should be used:
    • E.g., Pedialyte or Enfalyte
    • Breast-fed infants should continue to nurse
  • Goal: Provide 50–100 mL/kg of fluids over 2–4 hours. Route of administration depends on patient age and frailty:
    • Syringe or spoon-feeding
    • NG tube
  • +/– Ondansetron to prevent vomiting
  • Clinical hydration status should be monitored frequently.
  • Failure to improve with ORT should prompt IV hydration.

Severe dehydration

Severe dehydration can cause hypoperfusion of the brain and vital organs and is considered a medical emergency to be addressed rapidly.

  • Acute resuscitation phase:
    • Goal: correct or prevent hypovolemic shock
    • Rapid volume expansion through fluid boluses:
      • 20 mL/kg given over 20 minutes.
      • Can be repeated up to 3 times
      • Monitor vital signs between each bolus.
    • Choice of replacement fluid:
      • Isotonic fluids only
      • Either lactated Ringer’s or normal saline is appropriate.
    • Glucose monitoring:
      • Point-of-care monitoring for hypoglycemia
      • IV glucose should be administered.
      • 5–10 mL/kg of 10% dextrose in normal saline OR 2–4 mL/kg of 25% dextrose in normal saline
  • Resuscitation phase:
    • Slower replacement of lost fluids over 24 hours
    • Total fluid for resuscitation phase = maintenance fluids + (rehydration – bolus already given)
    • Rehydration is divided into 2 phases:
      • 50% over 1st 8 hours
      • 50% over next 16 hours
    • 5% dextrose with 0.2% sodium chloride compensates for maintenance requirement of sodium in most children
  • After 24 hours if clinically stable → continue maintenance fluids

Volume replacement calculations

  • Standard bolus:
    • 20 mL/kg/20 minutes
    • Up to 3 times
    • Monitor vital signs.
  • Maintenance calculations:
    • 4-2-1 rule:
      • 1st 10 kg = 4 mL/kg/hour
      • 2nd 10 kg = 2 mL/kg/hour
      • Additional kg = 1 mL/kg/hour
    • Example: For a child who weighs 37 kg:
      • (10 kg × 4 mL/kg/hour) + (10 kg × 2 mL/kg/hour) + (17 kg × 1 mL/kg/hour) =
      • (40 mL/hour) + (20 mL/hour) + (17 mL/hour) = 77 mL/hour
  • Rehydration is calculated by weight and severity of dehydration:
    • Amount calculated is added to maintenance amount, spread throughout the day.
    • < 10 kg:
      • Mild: 50 mL/kg/day
      • Moderate: 100 mL/kg/day
      • Severe: 150 mL/kg/day
    • ≥ 10 kg:
      • Mild: 30 mL/kg/day
      • Moderate: 60 mL/kg/day
      • Severe: 90 mL/kg/day

Complications

  • Dehydration
  • Malnutrition
  • Esophagitis
  • Intussusception
  • Sigmoid volvulus
  • Reflux

References:

  1. Maqbool, A., Liacouras, C. A. (2020). Major symptoms and signs of digestive tract disorders. In Kliegman, R.M., et al. (Eds.). Nelson textbook of pediatrics, pp. 1902.e.1–1912.e1. Retrieved March 24, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501003321
  2. CDC. (2015). Diarrhea: Common illness, global killer. https://www.cdc.gov/healthywater/global/diarrhea-burden.html 
  3. King, C.K., Glass, R., Bresee, J.S., Duggan, C. (2003). Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 52(RR-16):1–16. https://pubmed.ncbi.nlm.nih.gov/14627948/
  4. Lorenzo, C. (2020). Approach to the infant or child with nausea and vomiting. UpToDate. Retrieved March 27, 2021, from: https://www.uptodate.com/contents/approach-to-the-infant-or-child-with-nausea-and-vomiting
  5. Mullen, N. (2009). Vomiting in the pediatric age group. Pediatr Health 3(5):479–503. https://www.medscape.com/viewarticle/711641

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